Radiological Category Pediatrics Principal Modality 1 CT Principal

Case History 10 year-old boy presents with acute abdominal pain, nausea, vomiting. PMH of

Radiological Presentations Axial contrast-enhanced CT

Test Your Diagnosis Which one of the following is your choice for the appropriate

Findings and Differentials Findings: CT scout: Stomach is markedly distended with particular material Dilated

Findings and Differentials Findings: Malposition of SMA to the right of SMV. SMA SMV

Findings and Differentials Distended stomach and proximal jejunum loops

Findings and Differentials Duodenal and proximal jejunal loops wrap around the SMA/SMV, creating the

Findings and Differentials Dilation of distal SMV.

Findings and Differentials: • Midgut volvulus • Malrotation • Ladd’s bands

Discussion Normal rotation: After entering the mid-abdomen at 12 o'clock, the cecum rotates counterclockwise

Discussion Malrotation: Cecum remains around 12 o’clock position. Entire midgut is attached to the

Discussion Complications of Malrotation - Ladd’s bands, midgut volvolus. - Most presents during neonatal

Discussion Ladd’s bands Attempt to fix the colon to posterior abdominal wall results in

Discussion Midgut volvulus The floppy midgut can easily twist around the narrow mesentery, causing

Diagnosis UGI shows a normal position of ligament of Treitz and no signs of

Diagnosis : Intermittent midgut volvolus. Reference: Swischuk L. Pediatric Radiology: the Requisite, second edition,

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Radiological Category: Pediatrics Principal Modality (1): CT Principal Modality (2): Fluoroscopy Case Report #0203 Submitted by: Kim O Le , M. D. Faculty reviewer: Maria-Gisela Mercado-Deane, M. D Date accepted: 13 April 2005

Case History 10 year-old boy presents with acute abdominal pain, nausea, vomiting. PMH of Gastroschisis

Radiological Presentations CT scout

Radiological Presentations Axial contrast-enhanced CT

Radiological Presentations

Test Your Diagnosis Which one of the following is your choice for the appropriate diagnosis? After your selection, go to next page. • Adhesions • Appendicitis • Intussusceptions • Malrotation • Midgut volvulus • Peritoneal bands (Ladd’s bands)

Findings and Differentials Findings: CT scout: Stomach is markedly distended with particular material Dilated loops of proximal jejunum and right colon at the right upper quadrant.

Findings and Differentials Findings: Malposition of SMA to the right of SMV. SMA SMV

Findings and Differentials Distended stomach and proximal jejunum loops

Findings and Differentials Duodenal and proximal jejunal loops wrap around the SMA/SMV, creating the “whirlpool” sign SMA/SMV

Findings and Differentials Dilation of distal SMV.

Findings and Differentials: • Midgut volvulus • Malrotation • Ladd’s bands

Discussion Normal rotation: After entering the mid-abdomen at 12 o'clock, the cecum rotates counterclockwise into the right lower quadrant. The mesentery secures the small bowel to the posterior abdominal wall. Therefore, it is difficult for midgut to twist around this broad fan mesentery. Ligament of Treitz

Discussion Malrotation: Cecum remains around 12 o’clock position. Entire midgut is attached to the posterior abdominal wall by a short, narrow stalk in the region of the duodenum. Malrotation alone is asymptomatic. UGI shows abnormal position of ligament of Treitz, not in the left upper quadrant. US shows malposition of SMA to the right of SMV. BE shows malposition of cecum, usually in the right upper quadrant. cecum

Discussion Complications of Malrotation - Ladd’s bands, midgut volvolus. - Most presents during neonatal period with bilious vomiting, abdominal distension. However, it can occur at any age. - Ladd’s bands usually cause incomplete obstruction of 3 rd-4 th portion of duodenum. - The more turns midgut twist around the SMA, the higher risk of strangulation, and as a result bowel necrosis. Intermittent compromise of venous and lymphatic drainage can cause episodic abdominal pain and nausea vomiting.

Discussion Ladd’s bands Attempt to fix the colon to posterior abdominal wall results in the peritoneal bands (Ladd's Bands) crossing and extrinsically obstructing the duodenum. Duodenum Ladd’s bands UGI shows incomplete obstruction of the duodenum usually in the third and fourth parts, with evidence of extrinsic compression.

Discussion Midgut volvulus The floppy midgut can easily twist around the narrow mesentery, causing midgut volvulus. CT demonstrates ”whirlpool” sign. UGI shows “cork- screw” sign or “twisted-ribbon” sign.

Diagnosis UGI shows a normal position of ligament of Treitz and no signs of volvulus or Ladd’s bands. Patient was treated medically and symptoms were completely resolved after 2 days. Ligament of Treitz

Diagnosis : Intermittent midgut volvolus. Reference: Swischuk L. Pediatric Radiology: the Requisite, second edition, 1998, Baltimore, Mosby, pp. 106 -107. Blickman, J. Differential diagnosis in pediatric radiology, second edition, 1995, Portland, Lippincott Williams & Wilkins, pp 84.